[Locally recurrent and metastatic malignant melanoma. Long-term results and prognostic factors after percutaneous radiotherapy]

PURPOSE

Radiotherapy (RT) is used as last resort for patients with advanced cutaneous malignant melanoma (MM). Herein our 20-year clinical experience is presented analyzing different endpoints and prognostic factors in patients with locally advanced, recurrent or metastatic MM.

PATIENTS AND METHODS

From 1977 to 1995, 2,917 consecutive patients were entered in the MM registry of our university hospital. RT was indicated in 121 patients (56 females, 65 males) for palliation in locally advanced recurrent and metastatic MM stages UICC IIB to IV. At the time of RT initiation, 11 patients had primary or recurrent lesions which were either not eligible for surgery or had residual disease (R2) after resection of a primary or recurrent MM lesion (UICC IIB); 57 patients had lymph node (n = 33) or in-transit metastases (n = 24) (UICC III), and 53 had distant organ metastases (7 M1a, 46 M1b) (UICC IV). The time from first diagnosis to on-study RT averaged overall 19 months (median: 18; range: 3 to 186 months). In 77 patients conventional RT and in 44 patients hypofractionted RT was applied with 2 to 6 Gy fractions up to a mean total RT dose of 45 (median: 48; range: 20 to 66) Gy.

RESULTS

At 3 months follow-up, complete response (CR) was achieved in 7 (64%), overall response (CR + PR) in all (100%) UICC IIB patients, in 25 (44%) and 44 (77%) of 57 UICC III patients, and in 9 (17%) and 26 (49%) of 53 UICC IV patients. Tumor progression during RT occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median 10 months) (p < 0.01). At the time of evaluation and last FU (December 31, 1996), 26 patients were still alive: 6 (55%) stage UICC IIB, 17 (30%) stage UICC III, and 3 (6%) stage UICC IV patients (p < 0.01). Univariate analysis revealed following prognostic factors for CR and long-term survival: UICC stage (p < 0.001), primary location in the head and neck, total RT dose > 40 Gy (all p < 0.05), while age, gender and primary histological subtype had no impact. In multivariate analysis, UICC stage was the only independent favorable prognostic factor for achievement of CR and long-term survival (p < 0.001).

CONCLUSION

External RT provides effective palliation in advanced UICC stages. The UICC staging system is a good predictor of initial and long-term tumor response in metastatic MM. Prospective randomized trials using RT with or without adjuvant therapy for advanced MM are justified.

[Ulcerative stomatitis as clinical clue to inadvertent methotrexate overdose]

Gastrointestinal side effects and the development of toxic liver fibrosis are well-known side effects of low dose methotrexate therapy. A female patient receiving a long term low dose methotrexate therapy for a seronegative chronic polyarthritis developed an ulcerative stomatitis, as clinical clue to an inadvertently given methotrexate overdose. A summary of other side effects of methotrexate and of oral side effects of other cytostatic agents and immunosuppressive drugs is given.

[Long term results following radiation therapy of locally recurrent and metastatic malignant melanoma]

The 20-year radiotherapy (RT) experience in patients with locally advanced, recurrent or metastatic malignant melanoma (MM) is analyzed with respect to different endpoints and prognostic factors. From 1977 to 1995, 2917 consecutive patients were entered in our MM registry. RT was indicated in 121 patients (56 females, 65 males) for palliation in advanced MM stages. The histology of the primary lesion was nodular in 51, superficial spreading in 35, acral-lentiginous in 8 and lentigo maligna in 4 patients); 22 were missing or could not be reclassified. Eleven patients had primary or recurrent lesions which were ineligible for surgery or had residual disease (R2) after resection of a primary or recurrent lesion (UICC IIB); 57 patients had lymph node (33) or in-transit metastases (24) (UICC III), 53 had distant organ metastases (7 M1a; 46 M1b) (UICC IV). Time from first diagnosis to on-study RT averaged 19 (median: 18; range: 3-186) months. In most cases conventional RT was applied (2-6 Gy single fractions) up to a mean total RT dose of 45 (median: 48; range: 20-66) Gy. At 3 months follow-up (FU), complete response (CR) was achieved in 7 (64%) and overall response (CR+PR) in all (100%) UICC IIB patients, in 25 (44%)/44 (77%) of 57 UICC III patients, and in 9 (17%)/26 (49%) of 53 UICC IV patients. Progression during RT occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median: 10 months) (p<0. 01). At last FU, 26 patients were alive: 6 (55%) UICC IIB, 17 (30%) UICC III, and 3 (6%) UICC IV patients (p<0.01). In univariate analysis following favorable prognostic factors for CR and long-term survival were identified: low UICC stage (p<0.001), primary site head and neck and total dose >40 Gy (all p<0).

Papillary cystadenoma: a rare tumor of the minor salivary glands

Papillary cystadenoma of the minor salivary glands is a rare benign neoplasm that clinically resembles mucous cysts. Characteristic histological features are diagnostic. However, salivary gland histology is particularly difficult to interpret. Primarily, as further clinical and histological differential diagnoses have to take into account the well-differentiated cystic mucoepidermoid carcinoma and the papillary cystic type of acinic cell carcinoma, both malignant neoplasms of the salivary glands. We report on a 39 year old female with a bluish cystic lesion at the buccal mucosa, which occurred 14 years after the excision of a similar appearing, histologically proven mucous retention cyst at the same location. The histology of this tumor, however, revealed a papillary cystadenoma. Although rare, benign and malignant salivary gland neoplasms occur in minor salivary glands, and are clinically indistinguishable from mucous retention cysts. The dermatologist should be familiar with these differential diagnoses, since different therapeutic consequences result from an early diagnosis obtained by excision and histological examination of oral cystic tumors.

Palliative radiotherapy for recurrent and metastatic malignant melanoma: prognostic factors for tumor response and long-term outcome: a 20-year experience

PURPOSE

Radiotherapy is used as a "last resort" for patients with advanced cutaneous malignant melanoma. We have analyzed our 20-year clinical experience with respect to different endpoints and prognostic factors in patients with locally advanced, recurrent, or metastatic malignant melanoma.

METHODS

From 1977 to 1995, 2,917 consecutive patients were entered in the melanoma registry of our hospital. Radiotherapy was indicated in 121 patients (56 females, 65 males) for palliative reasons in advanced malignant melanoma stages UICC IIB/III/IV. The histology of the primary lesion was nodular in 51 patients, superficial spreading in 35, acral-lentiginous in 8, and lentigo maligna melanoma in 4 patients. Eleven patients had primary or recurrent lesions which were either not eligible for surgery or had residual disease (R2) after resection of a primary or recurrent lesion (UICC IIB); 57 patients had lymph node (n = 33) or in-transit metastases (n = 24) (UICC III), and 53 had distant organ metastases (7 M1a; 46 M1b) (UICC IV). Time from first diagnosis to on-study radiotherapy averaged 19 (median: 18; range: 3-186) months. In most cases, conventional RT was applied with 2-6 Gy single fractions up to a median total radiation dose of 48 (mean: 45; range: 20-66) Gy.

RESULTS

At 3 months follow-up, complete response (CR) was achieved in 7 (64%) and overall response [complete (CR) and partial response (PR)] in all (100%) UICC IIB patients, in 25 (44%) and 44 (77%) of 57 UICC III patients, and in 9 (17%) and 26 (49%) of 53 UICC IV patients. Tumor progression during radiotherapy occurred in 25 (21%) patients. Patients with CR survived longer (median: 40 months) than those without CR (median 10 months) (p < 0.01). At last follow-up (Dec 31, 1996), 26 patients were still alive: 6 (55%) UICC IIB, 17 (30%) UICC III, and 3 (6%) UICC IV patients (p < 0.01). Univariate analysis revealed the following prognostic factors for complete response and long-term survival: UICC stage (p < 0.001), primary location in the head and neck region, total radiation dose above 40 Gy (all p < 0.05), while age, gender, and histology had no impact. In multivariate analysis, UICC stage was the only independent prognostic factor (p < 0.001).

CONCLUSION

External beam radiotherapy can provide long-term local control and effective palliation in malignant melanoma UICC stages IIB-IV. The current UICC staging system is an excellent prognostic factor for initial and long-term tumor response in metastatic melanoma. Therefore, prospective randomized trials using external radiotherapy with or without adjuvant therapy for advanced malignant melanoma are justified.

Differentiation between Spitz nevi and malignant melanomas by interphase fluorescence in situ hybridization

Spitz nevi are benign melanocytic neoplasias which have distinct pathological features that make the pathological differential diagnosis from malignant melanomas extremely difficult. The Spitz nevi may be misdiagnosed as malignant melanoma and vice versa. Therefore, interphase fluorescence in situ hybridization (I-FISH) was used for a possible discrimination between Spitz nevi and malignant melanomas on the basis of numerical aberrations of the chromosome complement in interphase nuclei of thin sections. Previous studies had shown changes in malignant melanomas which were not found at the same level in normal tissue or benign tumors. Thin sections of archival paraffin material from 42 Spitz nevi with different histological type and grade of anomaly were subjected to FISH-analyses using commercially available biotinylated and/or digoxigenated alphoid DNA probes of chromosomes 1, 6, 7, 9, 17 and 18, which were applied in combinations in a two- or three-color-FISH. Unaffected epithelial areas from the same sections served as. The obtained data were compared with those collected previously from thin sections of malignant melanomas prepared in the same way. Due to the sometimes limited nevus area investigated, the number of evaluable nuclei was lower than expected from previous experiences with malignant melanomas. Therefore, only 20 nevi could be reliably evaluated. The comparison of the group of Spitz nevi with the group of controls did not show any significant difference regarding chromosomes 1, 6, 7, 9 and 17 (Wilcoxon test). The method used to detect chromosomal loss or gain in the individual Spitz nevi demonstrated only two nevi (one of the spindle cell type with a low to middle grade of anomaly, the other of the epitheloid cell type with a middle grade of anomaly) with a gain of chromosome 7 and chromosome 17, respectively. So, with respect to the histological type and grade of anomaly, no numerical aberrations could be detected in Spitz nevi. The comparison of the group of Spitz nevi with subgroups of malignant melanomas (metastatic, non-metastatic, melanomas with a thickness <1.5 mm and melanomas with a thickness >2. 0 mm) and with the whole group of malignant melanomas showed significant differences concerning chromosome 9 (Mann-Whitney U test), signal indices, which were higher in the melanomas than in the Spitz nevi. Regarding chromosomes 6, 7 and 17 no significant differences could be shown, although a trend of gain in melanomas and of loss in Spitz nevi was observed of these chromosomes.

Deletion monitoring in skin tumors by interphase-FISH using band-specific DNA probes

Thin sections from archival paraffin blocks of various skin tumors (26 melanomas, 15 squamous cell carcinomas, 5 keratoacanthomas, 5 basal cell carcinomas) were subjected to interphase-FISH (I-FISH) with DNA probes which are specific for chromosomal regions often involved in deletions in human cancer. These were probes for chromosome 3p21, the p53 gene on chromosome 17p13, and, in a few selected cases, a probe for chromosome 9p21. It was demonstrated that deletions of these regions could be reliably detected and related to tumor type and histology, i.e. grading. The most common deletion was that of 3p21 which was found in all studied squamous cell carcinomas (SCC) of low differentiation, in 60% of the Bowen carcinomas, in 70% of the metastatic melanomas less than 1.5 mm thick, and in over 55% of those which thickness over 2 mm. In contrast, FISH-detected p53 deletion was a rare finding in the investigated tumors. However, this gene was even found in an increased copy number in 60% of the poorly differentiated SCCs (grade 4) and in 50% of the non-metastatic melanomas less than 1.5 mm thick. Deletion of 9p21 was detected in 13 of the 14 tumors on which pertinent examinations could be performed. I-FISH was shown to be a reliable technique for the rapid detection of chromosome band specific deletions in archival material of human skin tumors.

[Papillary cystadenoma of the minor salivary glands]

Papillary cystadenoma of the minor salivary glands is a rare benign tumor that clinically resembles a mucous cyst. We demonstrate its histologic features and differential diagnosis by a case report. Benign and malignant neoplasms of the minor salivary glands are not well acknowledged in the dermatologic literature, but should be considered in the differential diagnosis for mucous cysts.

[Dose-dependent pellagroid skin reaction caused by carbamazepine]

A 11-year-old girl suffering from grand mal epilepsy underwent antiepileptic therapy with carbamazepine (600 mg/daily). Two weeks after increasing the dose (900 mg/day) she suddenly developed relatively sharply limited, sunburn-like brown reddish macular lesions with central scaling and partly hyperkeratotic areas on the hands, feet, face, knees, gluteal and axillar regions. Otherwise no health disorders were found; in particular no neurological or gastrointestinal symptoms occurred. After reduction of the doses (450 mg/day) these skin lesions faded away. With exception of elevated serum levels of carbamazepine, nicotinamide and vitamin B6, all blood tests were in normal range. Interactions of carbamazepine with the vitamin B6- nicotinamide metabolism are the reason for these previously undescribed cutaneous side effects in connection with carbamazepine therapy. The present case demonstrates a toxic, non-allergic reaction during carbamazepine treatment with pellagroid skin symptoms.

Interphase-FISH examinations in paraffin sections from benign, precancerous, and cancerous lesions of the skin and oral mucosa

In a preliminary pilot study centromeric probes for chromosomes #7, #8, #11, and #17 and two-colour-FISH were applied on interphase nuclei of 10 coded histologic thin sections obtained from archival paraffin material from precancerous lesions and malignant tumors of the mouth epithelium. Brilliant signals could be obtained in this material without any computerized processing. Among the ten coded probes, localized malignant areas within grade 2 leukoplakias could be detected by their increased number of aneusomic cells, as could the samples from carcinomas. In extension of this study archival paraffin material from 30 epithelial tumors of the skin were examined. The studied squamous cell and Bowen carcinomas were characterized by a large number of chromosomally aberrant subclones and gains of chromosomes were the prevailing finding. In contrast, keratoacanthomas showed distinctly less clonal variation, their majority exhibiting small, but significant clones with chromosome loss, particularly of chromosome #7, less distinctly of chromosome #17.

Chromosome gain and loss in paraffin sections from malignant melanomas of the skin

Alphoid DNA probes specific for the chromosomes #6, #7, #9, and #17 were used to screen interphase nuclei for numerical chromosome aberrations in histologic thin sections obtained from archival paraffin material of 25 human melanomas of different type, thickness and stage of progression. An alphoid probe for chromosome #3 was applied in four of these tumors. Besides a general large variation of the number of subpopulations of cells characterized by gains and losses of the studied chromosomes, there was a trend to higher variability in metastatic melanomas as compared to small (<1.5 mm thickness) non-metastatic ones and, particularly, to normal skin tissue. Chromosomes #6 and #9 were those often affected by loss in thick melanomas (>2 mm), while subpopulations showing a gain of these chromosomes, and, in addition, of chromosome #7 seemed more frequently to be associated with thin and non-metastatic ones. The frequency of cases showing gain of chromosome #17 clearly exceeded those with loss of this chromosome in the studied melanomas, but was most pronounced in thicker metastatic tumors.

Clinical relevance of sonometry-derived tumour thickness in malignant melanoma--a statistical analysis

High-frequency sonography has been shown to be a useful tool in planning operative strategy in the surgery of malignant melanoma (MM). The purpose of the present study was to compare sonometric and histometric data of tumour thickness in primary cutaneous MM, applying statistical methods in order to evaluate the pre-operative relevance of sonometry. The thickness of 259 melanomas was measured preoperatively by a 20-MHz B scan, and postoperatively by histometry. Statistical analysis was performed using Pearson's correlation coefficient and absolute and relative differences. Although the correlation between sonometry and histometry was good (r = 0.88), there was a mean difference of 0.39 mm (relative difference 28%). Overall, sonometry was in agreement with the corresponding histological classes in 75% of cases. However, tumours assessed by ultrasound as between 0.55 and 0.95 mm thick were incorrectly classified according to histology in 34%, and those between 1.30 and 1.70 mm were incorrectly classified in 50% of cases. Our data reveal greater differences between sonometry and histometry using appropriate statistical methods. A concept to assess differences between sonometry and histometry is recommended.

[Hair growth promoters in androgenetic alopecia. Expectations and reality]

Androgenetic hair loss is the most frequent reason for the topical application of hair-growth-promoting agents. Such preparations should arrest or even reverse androgen-induced hair follicle regression as well as prolonging the hair cycles, especially of the shortened anagen phase, and thus protect from increased hair loss. True evidence of drug effects on hair growth is problematic, since trichograms, the method chiefly applied by the manufacturers, fail to reveal every factor involved in the follicular activity, especially the duration of anagen stage. For example, an increase in the anagen rate does not always reflect a lengthening of the anagen stage, but may also be due to shortened hair cycles. Accordingly, drug effects on hair growth should be investigated by methods that analyse the cell cycle kinetics. For this approach DNA-flowcytometry of the outer root sheath in plucked anagen hairs and of complete anagen hair bulbs taken by micropreparative techniques from scalp biopsies offers a reproducible method for quick and reliable evaluation of hair growth.

Cell kinetics of anagen scalp hairs under physiological and pathological conditions

The cell kinetics of anagen scalp hair bulbs taken by punch biopsies from healthy male volunteers (n = 50) were determined at defined bulbar hair segments using microdissection and DNA flow cytometry. The highest proliferative activity (S phase) was measured within the lower most bulbar segment (14.0%) but decreased to the Auber's segment (7.6%) and to the isthmus segment (5.9%). The results support histoautoradiographic data demonstrating most of the proliferative activity in the hair bulb below the Auber's level [1]. Furthermore, cell kinetic data of dissected anagen hair bulbs segmented at Auber's level from an androgen-sensitive scalp area were studied in male pattern baldness (n = 15, Hamilton IV) and hirsutism (n = 13). The results revealed a significant increase of S phase cells in male pattern baldness (8.9%) compared to healthy males (n = 10, 7.9%) as well as in hirsutism (10.2%) compared to healthy females (n = 10, 7.5%). In hirsutism the percentages of S phase cells ran parallel to the plasma levels of dehydroepiandrosterone sulfate whereas no correlation to testosterone could be proved. Similar, 6 hypothyroid and 6 hyperthyroid patients were studied. In hyperthyroidism an increase of S phase values (10.3%) was found, while it decreased in hypothyroidism (6.1%). A correlation between the height of S phase and plasma triiodothyronine level was noted. Our studies demonstrate that DNA flow cytometry is a suitable method for the evaluation of physiological or hormonal influences on cell cycle kinetics of human anagen hair bulbs in vivo.

Sex hormones and antiandrogens influence in vitro growth of dermal papilla cells and outer root sheath keratinocytes of human hair follicles

Anagen hair bulb papillae, interfollicular dermal fibroblasts, and interfollicular keratinocytes isolated from fronto-parietal scalp biopsies as well as outer root sheath keratinocytes from plucked anagen hairs were separately grown in subculture for 14 d. The effect of different concentrations (2.4 nM-17.3 microM) of testosterone, dihydrotestosterone, and the antiandrogens cyproterone acetate or 17 alpha-propylmesterolone on growth behavior of the mesenchymal and epithelial cell types of the hair follicle were comparatively studied by means of growth curves, cell doubling times, and 3H-thymidine incorporation. For control, all cell lines were subcultured in hormone-free medium. Testosterone and dihydrotestosterone (345 nM) significantly reduced proliferation of papilla cells compared with dermal fibroblasts (p < 0.01) and outer root sheath keratinocytes compared with interfollicular keratinocytes (p < 0.01), as well as compared with cells cultured in control medium. Low concentrations of 17 beta-estradiol were ineffective, whereas doses of 180 nM 17 beta-estradiol increased the growth velocities of all cell types, especially of papilla cells, compared with dermal fibroblasts. Low doses of either cyproterone acetate (24 nM) or 17 alpha-propylmesterolone (29 nM) induced a growth enhancement, especially of papilla cells and outer root sheath keratinocytes, whereas high doses of cyproterone (1.20 microM) and 17 alpha-propylmesterolone (1.45 microM) had opposite effects. These changes were significant between papilla cells and dermal fibroblasts as well as between outer root sheath keratinocytes and interfollicular keratinocytes. Applying increasing doses of androgens to cyproterone acetate (24 nM)- or 17 alpha-propylmesterolone (29 nM)-containing media neutralized the growth-stimulating effect of antiandrogens, particularly in papilla cells and outer root sheath keratinocytes. However, minor differences between testosterone and dihydrotestosterone effects on cell growth were found. The data clearly demonstrate that the changes of in vitro growth of hair follicle cells depend on the concentrations of androgens and antiandrogens, as higher doses of both antiandrogens tested retarded the cell proliferation similar to testosterone or dihydrotestosterone. The papilla cells and outer root sheath keratinocytes reacted more sensitively to the hormones tested, thereby confirming the concept of a distinct androgen sensitivity of these specialized hair follicle cells.

[Incidence of ocular pigment changes in patients with cutaneous melanoma]

Between October 1990 und April 1992, 116 patients with primary cutaneous melanoma and 6 with primary ocular malignant melanoma underwent both dermatological and ophthalmological examination, standardized personal and clinical criteria being applied. In addition to the record of the DDG melanoma file, the skin type, eye and skin colour, number of naevi, occurrence of any other cutaneous alterations, and the family history with respect to additional malignant neoplasms were documented. It was found that 18/116 patients with cutaneous melanoma also had naevi of the iris, but none had concomitant ocular melanoma. Notably, 32% of first degree relatives (n = 37) had a malignant neoplasm, as against 12% of the dermatological patients with no oncological conditions who acted as controls. Although the occurrence of additional changes in ocular pigmentation alterations in patients with malignant cutaneous melanoma cannot be regarded as significant on the basis of our prospective study, the eye, as a potential location of metastases or the original site in primary malignant melanoma, should be examined during staging and follow-up examinations, especially as isolated cases of oculo-cutaneous correlation have already been reported.

Distribution of adhesion molecules, IgE, and CD23 in a case of angiolymphoid hyperplasia with eosinophilia

Angiolymphoid hyperplasia with eosinophilia developed in a 13-year-old boy. The immune phenotype of infiltrating cells and the distribution of adhesion molecules of the integrin, immunoglobulin, and selectin families were analyzed with monoclonal antibodies. The infiltrate consisted mainly of helper lymphocytes, monocytes, eosinophils, CD1+ dendritic cells, and mast cells. A CD23/Fc epsilon receptor was present on 40% of these cells, and surface bound IgE was present on 30% of these cells. The latter was found on all cell types. A cellular adhesion molecule analysis revealed that the proliferating endothelial cells were expressing constitutive ICAM-1, LFA-3, VLA-1, VLA-3, VLA-5, alpha 6, and beta 3-integrin chain as well as activation-dependent VLA-2, VCAM-1, and human lymphocyte antigen-DR. The infiltrating cells expressed LFA-1 and CD2, the correlating ligands for ICAM-1 and LFA-3. Our studies support previous observations of an unusual IgE-mediated immune reaction, and suggest an additional pathogenic role for adhesion events in the development of the pathognomonic cellular composition in angiolymphoid hyperplasia with eosinophilia.

In situ [3H]thymidine labelling of human hair papilla: an in vitro autoradiographic study

The labelling index (LI) and the location of labelled cells in the papilla of human anagen scalp hair have been studied after in vitro [3H]thymidine (3H-TdR) pulse labelling. Forty-three anagen stage VI papillae from 2 individuals (both females, 25 and 55 years) obtained by micropreparation from deep scalp biopsies were analysed. Labelled cells were found only paraaxially in the basal third of the papilla, i.e. below Auber's line. The 3H-TdR-LI of the papilla cells (0.13 and 0.16%) is about 200-times lower than that of the hair matrix cells below the line of Auber (25.5 and 29.5%). The biological significance of this low proliferation rate in the anagen stage VI hair papilla of healthy human should be defined.